Neurology
Neurology questions centre on reperfusion windows, seizure escalation, and neuromuscular respiratory failure - plus recognising the stroke mimics.
Acute ischaemic stroke
Non-contrast CT excludes haemorrhage. IV thrombolysis is offered within 4.5 h of last-known-well if BP <185/110, glucose is normal, and there is no contraindication. Mechanical thrombectomy is available up to 24 h in selected large-vessel occlusion with favourable imaging. Give aspirin 24 h after thrombolysis (immediately if not thrombolysed) and keep BP <180/105 afterwards.
Status epilepticus
At 5 min give a benzodiazepine (IV lorazepam 0.1 mg/kg). At 20 min add a second-line IV agent (levetiracetam, valproate, or phenytoin). At 40 min the patient is refractory: intubate and infuse propofol or midazolam while searching for the cause - glucose, sodium, infection, withdrawal.
Neuromuscular emergencies
Guillain-Barré: ascending symmetric weakness with areflexia and albuminocytologic dissociation; intubate when vital capacity falls below 20 mL/kg or drops >30%. Myasthenic crisis: bulbar weakness and ptosis; treat with plasma exchange or IVIG and avoid aminoglycosides and fluoroquinolones.
Headache red flags
Thunderclap onset, fever with neck stiffness, new focal deficit, papilloedema, new headache over age 50, positional worsening, malignancy, and pregnancy or postpartum (cerebral venous thrombosis).
Worked example
A 70-year-old has sudden dense left hemiparesis, NIHSS 18, onset 90 min ago. CT shows no blood, glucose 100 mg/dL, BP 172/95. Give IV thrombolysis and, in parallel, screen for large-vessel occlusion for thrombectomy. Reasoning: both decisions proceed simultaneously; waiting for the vascular study before thrombolysis wastes the window.
Traps that cost marks
- Lowering blood pressure aggressively in acute ischaemic stroke without a defined indication.
- Missing hypoglycaemia as a stroke mimic.
- Waiting for EEG before giving the first benzodiazepine.